Contractor Payment Request Short Version

Instructions for Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 The Contractor Payment Request workbook was created in Microsoft Excel XP, Version 2003 SP2. There are ten (10) worksheet tabs that comprise the entire document The last tab is for office use only and is not completed by the contractor. In most of the tabs there are multiple pages. Please review the entire document prior to commencing. The Contractor Payment Request is to provide an accurate and detailed breakdown for the Work, in accordance with the requirements of Article 9 of the General Conditions and following the preferred titles and sequences in the Construction Specifications Institute (CSI) used in the Specifications. The Associate and the Construction Manager (if applicable) will review the Contractor Payment Request for accuracy and completeness; no payment will be made without an approved Contractor Payment Request The detail required on the schedule of values of the Contractor Payment Request is to allow for easy confirmation of the status of each item of Work. For example, a multi-story building should include a “per floor” item for finish Work by the general Contractor such as metal studs, drywall and paint; or a large single story building may be broken down “by wing” and the same metal studs, drywall and paint. Mechanical and electrical Contractors will include separate line items for all major pieces of equipment and group small equipment items by type. These trades are requested to follow the “per floor” or “per wing” approach for rough in, wiring, and device hookup, or for piping and hookup. The line items for labor and material shall accurately reflect the cost for each item; separate items are not to be shown for overhead or profit, but should be included in the totals for labor and materials. Legend Cell Colors as Used on Forms Yellow Turquoise Red Lavender Light Turquoise Pale Blue Tan Normal entry information Information entered under special circumstances Enter maximum retainage only after first 50%+ pay request Information to copy from Information to copy to Check appropriate box Optional Area For Calculation General Instructions for Contractor Payment Request In accordance with Instructions to Bidders 7.4.1.5 of the Standard Conditions of Contract for Construction, all Contractors must provide evidence that an authorization agreement for automatic deposit of state warrants has been submitted to the Auditor of the State of Ohio. Use of electronic funds transfer (EFT) will normally result in payment 7 to 10 days earlier than by State warrant. Payment to the Contractor will be processed according to Article 9 of the General Conditions. The procedure for reviewing and approving payment requests shall be established at the pre-construction meeting. On larger Projects, it is advisable to distribute a pencil copy of the payment request for preliminary review by the Associate and the Construction Manager (if applicable) one week before formal submittal. The Contractor will submit the required number of copies of the executed payment request. Original signatures are required on all copies and are requested in blue ink. The payment request is processed by the Office of the State Architect (SAO) and returned to the Owner for vouchering, however, some Owners prefer to review, approve and voucher the payment request before submitting to SAO. SAO-F140-02v0408, ADM 5854 Instructions, Page 1 of 3 Instructions for Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 The Contractor shall submit a certified payroll report with each payment request which includes labor, see Section 9.2.1.2 of the General Conditions. One (1) certified payroll report is required for each week of Work reflected on the payment request. Any payment request, which does not include labor, requires a certified payroll report indicating the period covered by the payment request specifically noting that “no labor was performed during this period.” SAO requests one copy of the certified payroll reports (for the Contractor and all Subcontractors who performed labor for requested period) be attached to the back of the second copy of the payment request to reduce the possibility that someone requiring a copy of the payment request will also take the certified payroll. The Contractor shall request payment for Change Orders which have been approved and for which Work was performed during the time covered by the payment request. If a Contractor is requesting payment for materials delivered on the Project site or other approved storage site, the Contractor shall complete the Materials Stored section of this application. The Contractor shall pay any travel expenses incurred by the Associate or the Construction Manager (if applicable) to visit a storage site other than the Project location. Retainage is to be held on payment requests in the amount of eight percent (8%) of labor until a construction Contract has reached fifty-percent (50%) completion. The calculation for determining whether the Contract has reached fiftypercent (50%) completion is as follows: total labor and material “billed” to date to include approved stored materials divided by total Contract amount plus total Change Orders approved to date. The Contractor will be asked by SAO to sign an escrow agreement soon after Contract award. When a payment request is received that exceeds 50 percent as calculated above, SAO will transfer the retainage into escrow where it will earn interest. If a Contractor fails to return the escrow agreement, no escrow can be established. In order to request final payment, the payment request must include the following: required payroll reports, a Certification of Contract Completion evidencing that all Project record document submittals are satisfactory and an Affidavit of Contractor to certify compliance with prevailing wage and payment to Subcontractors and Material Suppliers. Escrow funds remain on account with the escrow agent until the final, 100 percent payment is requested, a Contract Completion Certificate is issued and a signed Affidavit of Contractor has been received. At that time, escrow and earned interest are released and forwarded to the Contractor. An early release of escrow may be allowed if Change Orders are issued late in the Contract and the Contractor has completed 100 percent of the base Contract Work. Step By Step Instructions Initial Schedule of Values At the beginning of the Contract each Contractor is required to complete the basic information at the top of the Section A – Summary page (area in yellow except for request number and period) as well as columns a through d of Section B – Schedule of Values Summary (items 1 through 8 plus area in yellow) for as many line items as are required. Prior to entering the line items on Schedule B, the contractor should fill out Tab H - EDGE to include all EDGE subcontractors and suppliers expected to be used. The EDGE subcontractors must also be entered on Tab G - Subcontractors. Use of EDGE vendors must be identified on the Schedule of Values by entering the corresponding alpha character from column a of tab H - EDGE into column b of the Schedule of Values along with the other required data. The Schedule of Values must then be signed by the Contractor and submitted to the Associate and the Construction Manager (if applicable) for approval. The Schedule of Values will then be forwarded to the Project Manager for final approval. The Contractor will receive a signed copy of the approved Schedule of Values. No payment requests will be processed before the Schedule of Values has been approved. Note: If you are trying to enter data into a cell and get a pop-up warning that you cannot enter into a protected cell you are trying to enter data where you should not be. Data is NEVER entered into a cell that is white or lavender. SAO-F140-02v0408, ADM 5854 Instructions, Page 2 of 3 Instructions for Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 Payment Request 1. Contractor Payment Requests are normally submitted on a monthly basis 2. Enter Request No. and dates from and to on Section A – Summary 3. Go to Section C – Schedule of Values Details. Enter amounts from previous applications in columns e and f (light turquoise). Enter amounts for current period in columns h and i. If you prefer you can move the cursor to the right, off the form and enter the percentage complete for any or all of the line items. Note: You should be able to copy the information you need to enter in columns c and d from Section B – Schedule of Values Summary columns k and l (lavender color) of the previous Contractor Payment Request. When you paste the information you will need to use "paste special and click on "values and number formats" 4. Go to Section D - Change Order Summary. Enter all Change Orders that have been approved since the last payment request that was submitted in columns a through f (yellow area). You must separately identify EDGE vendors used. 5. Go to Section E - Change Order Details. Enter amounts from previous applications in columns c and d (light turquoise). Enter amounts for current period in columns f and g. If you prefer you can move the cursor to the right, off the form and enter the percentage complete for any or all of the line items. Note: You should be able to copy the information you need to enter in columns c and d from Section D – Change Order Summary columns I and j (lavender color) of the previous Contractor Payment Request. When you paste the information you will need to use "paste special and click on "values and number formats" 6. Go to Section F - Stored Materials. Enter information as required. Be sure to check each item as to whether stored on or off site. 7. Go to Section G - Subcontractors. List ALL Subcontractors. Check whether or not each Subcontractor was used during the period covered by this request. Check whether or not payrolls are attached. Check whether or not apprenticeship agreement has been submitted. Check whether or not payrolls have been submitted for each Subcontractor. Note: You are responsible for obtaining and providing payrolls for all of the Subcontractors you use. Failure to provide payrolls for all Subcontractors used during the period of this request is a violation of your Contract. 8. Go to Section A - Summary. Amounts completed to date have been calculated and carried forward to the summary page based upon the data you have entered. Retainage to date has also been calculated and entered. Also entered is the percentage that this Contract is now complete based upon the information entered. If the percent complete shows 50% or more complete and this is the first pay request for which this has been the case the amount of retainage shown will be the final total for retainage for this contract and you should override the calculation for retainage on all future pay requests for this contract and enter this amount on all future pay requests. Enter the amounts which should be withheld for liens, Liquidated Damages or other withholdings about which you have been informed. Enter the amount of previous payments from previous pay request. At this point the form has calculated the amount due on this payment request. 9. Print the Section A - Summary page. Then go to each tab (Worksheet) and print the number of pages on which you have entered data on this contract. Each Worksheet will display the number of pages on that Worksheet in the bottom right hand corner of every page. If it reads Page 1 of 5 in the bottom right you would want to print 5 pages of that Worksheet. The entire Workbook contains over 110 pages so you would not want to print all of the pages in the Workbook as many of them are unnecessary for most contracts. 10. You should now have one copy of the entire Contractor Payment Request. Make as many copies of the payment request as the Associate has told you that you will need to submit for this contract. Sign each copy. Attach the required payrolls to the second copy as instructed above. Submit all copies to the Associate for approval and further processing. Please refer any questions or concerns about the forms to your project coordinator. SAO-F140-02v0408, ADM 5854 Instructions, Page 3 of 3 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name and Address Project Information SAO Contract No. Local No. Project Name & Location Contr. Phone Contr. Fax Contr. Tax ID Contr. E-mail Contractor Certification Contractor certifies the Original Application values in this Payment Request have not changed from the values first approved, all information in this Payment Request is true and accurate, all payments received to date have been used by the Contractor to discharge, in full, the obligations incurred and provided during the periods for which payment was made, and the Contractor has, to the best of its knowledge, completed the Work to date in accordance within the terms and conditions of the contract, including payment of the applicable Prevailing Wage rates. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 Associate Name and Address A - Summary Request No. Sheet 1 of 1 CM Name and Address For the period from Type of Contract Partial Payment Details Completed to date Original Contract Amount Change Order Amount Stored Materials Subtotal - Earned (A) Percent Complete Labor $ to Materials $ Total $ N/A Authorized signature Date Work Progress Certification Each firm signing below certifies that, based upon its on-site observations, the payment requested to date is a fair and reasonable request for the Work provided to date. Withheld Amounts Lien(s) Retainage Amount Liquidated Damages Other Subtotal - Withheld (B) Lead Contractor Associate Construction Manager Date Previous Payments (C) Date Date Total Requested this Application (A - B - C) Owner Approvals State Architect's Office Approval Authorized signature SAO-F140-02v0408, ADM 5854 Date Authorized signature Date Authorized signature Date Section A - Summary, Page 1 of 1 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 B - Schedule of Values Summary Request No. Sheet 2 of 1 a. b. EDGE c. Section 00 61 00 00 62 16 00 72 00 01 31 13 01 7 113 01 77 00 01 21 00.01 01 21 00.02 Bond Insurance d. Description e. Original Labor $ Original Application f. Original Material $ Current Period g. Original Total $ h. Completed to Date $ i. % this Period j. % to Date k. Labor to Date $ l. Material to Date $ Item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 General Conditions Project Coordination Mobilization Close-out Items Allowance: Sched. Consultant Allowance: Project Identification Total this Sheet Section B - Schedule of Values Summary, Page 1 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 B - Schedule of Values Summary Request No. Sheet 3 of 1 a. b. EDGE c. Section d. Description e. Original Labor $ Original Application f. Original Material $ Current Period g. Original Total $ h. Completed to Date $ i. % this Period j. % to Date k. Labor to Date $ l. Material to Date $ Item 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Total this Sheet Section B - Schedule of Values Summary, Page 2 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 B - Schedule of Values Summary Request No. Sheet 4 of 1 a. b. EDGE c. Section d. Description e. Original Labor $ Original Application f. Original Material $ Current Period g. Original Total $ h. Completed to Date $ i. % this Period j. % to Date k. Labor to Date $ l. Material to Date $ Item 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 Total this Sheet Section B - Schedule of Values Summary, Page 3 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 B - Schedule of Values Summary Request No. Sheet 5 of 1 a. b. EDGE c. Section d. Description e. Original Labor $ Original Application f. Original Material $ Current Period g. Original Total $ h. Completed to Date $ i. % this Period j. % to Date k. Labor to Date $ l. Material to Date $ Item 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 Total this Sheet Section B - Schedule of Values Summary, Page 4 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 C - Schedule of Values Details Request No. Sheet 2 of 1 a. b. EDGE c. Section 00 61 00 00 62 16 00 72 00 01 31 13 01 7 113 01 77 00 01 21 00.01 01 21 00.02 Bond Insurance d. Description e. Previous Applications to Date f. g. Previous Material $ Previous Total $ Current Period h. Labor this Period $ i. Material this Period $ j. Labor to Date $ k. Material to Date $ Item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Previous Labor $ General Conditions Project Coordination Mobilization Close-out Items Allowance: Sched. Consultant Allowance: Project Identification Total this Sheet Section C - Schedule of Values Details, Page 1 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 C - Schedule of Values Details Request No. Sheet 3 of 1 a. b. EDGE c. Section d. Description e. Previous Applications to Date f. g. Previous Material $ Previous Total $ Current Period h. Labor this Period $ i. Material this Period $ j. Labor to Date $ k. Material to Date $ Item 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Previous Labor $ Total this Sheet Section C - Schedule of Values Details, Page 2 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 C - Schedule of Values Details Request No. Sheet 4 of 1 a. b. EDGE c. Section d. Description e. Previous Applications to Date f. g. Previous Material $ Previous Total $ Current Period h. Labor this Period $ i. Material this Period $ j. Labor to Date $ k. Material to Date $ Item 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 Previous Labor $ Total this Sheet Section C - Schedule of Values Details, Page 3 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 C - Schedule of Values Details Request No. Sheet 5 of 1 a. b. EDGE c. Section d. Description e. Previous Applications to Date f. g. Previous Material $ Previous Total $ Current Period h. Labor this Period $ i. Material this Period $ j. Labor to Date $ k. Material to Date $ Item 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 Previous Labor $ Total this Sheet Section C - Schedule of Values Details, Page 4 of 0 SAO-F140-02v0408, ADM 5854 www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 Optional Calculation Labor Material % To Percent Percent Date Section C - Schedule of Values Details, Page 1 of 0 SAO-F140-02v0408, ADM 5854 www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 Optional Calculation Labor Material % To Percent Percent Date Section C - Schedule of Values Details, Page 2 of 0 SAO-F140-02v0408, ADM 5854 www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 Optional Calculation Labor Material % To Percent Percent Date Section C - Schedule of Values Details, Page 3 of 0 SAO-F140-02v0408, ADM 5854 www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 Optional Calculation Labor Material % To Percent Percent Date Section C - Schedule of Values Details, Page 4 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Change Order Info a. CO No. b. EDGE www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. D - Change Order Summary Request No. Sheet Current Period 2 of 1 c. Section d. Date Approved e. Change Order Labor $ f. Change Order Material $ g. Change Order Total $ h. % this Period i. % to Date j. Completed to Date $ k. Labor to Date $ l. Material to Date $ Total this Sheet Section D - Change Order Summary, Page 1 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Change Order Info a. CO No. b. EDGE www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. D - Change Order Summary Request No. Sheet Current Period 3 of 1 c. Section d. Date Approved e. Change Order Labor $ f. Change Order Material $ g. Change Order Total $ h. % this Period i. % to Date j. Completed to Date $ k. Labor to Date $ l. Material to Date $ Total this Sheet Section D - Change Order Summary, Page 2 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Change Order Info a. CO No. b. EDGE www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. D - Change Order Summary Request No. Sheet Current Period 4 of 1 c. Section d. Date Approved e. Change Order Labor $ f. Change Order Material $ g. Change Order Total $ h. % this Period i. % to Date j. Completed to Date $ k. Labor to Date $ l. Material to Date $ Total this Sheet Section D - Change Order Summary, Page 3 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Previous Applications to Date f. g. Previous CO Material $ Previous CO Total $ www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. E - Change Order Details Request No. Sheet Current Period h. CO Labor this Period $ i. CO Material this Period $ j. CO Labor to Date $ k. CO Material to Date $ 2 of 1 EDGE a. b. CO No. c. Section d. Date Approved e. Previous CO Labor $ Total this Sheet Section E - Change Order Details, Page 1 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Previous Applications to Date f. g. Previous CO Material $ Previous CO Total $ www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. E - Change Order Details Request No. Sheet Current Period h. CO Labor this Period $ i. CO Material this Period $ j. CO Labor to Date $ k. CO Material to Date $ 3 of 1 EDGE a. b. CO No. c. Section d. Date Approved e. Previous CO Labor $ Total this Sheet Section E - Change Order Details, Page 2 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Previous Applications to Date f. g. Previous CO Material $ Previous CO Total $ www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. E - Change Order Details Request No. Sheet Current Period h. CO Labor this Period $ i. CO Material this Period $ j. CO Labor to Date $ k. CO Material to Date $ 4 of 1 EDGE a. b. CO No. c. Section d. Date Approved e. Previous CO Labor $ Total this Sheet Section E - Change Order Details, Page 3 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Line Ref. Invoice No. Material Supplier Previous Stored Amount New Materials Stored (Add) Request No. Sheet 2 of 1 SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 F - Stored Materials On Off Description Mat. Installed this Period (Deduct) Current Material Stored Total This Sheet Section F - Stored Materials, Page 1 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location Line Ref. Invoice No. Material Supplier Previous Stored Amount New Materials Stored (Add) Request No. Sheet 3 of 1 SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 F - Stored Materials On Off Description Mat. Installed this Period (Deduct) Current Material Stored Total This Sheet Grand Total (Final Sheet Only) Payments Allowed @ 92% Section F - Stored Materials, Page 2 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location List all Subcontractors Utilized This Pay Period Yes No Payrolls Attached Yes No www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. G - Subcontractors Request No. Sheet Apprent. Agree. Submited Yes No 2 of 1 Pay. Sched. Submitted Yes No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Section G - Subcontractors, Page 1 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location List all Subcontractors Utilized This Pay Period Yes No Payrolls Attached Yes No www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 SAO Contract No. G - Subcontractors Request No. Sheet Apprent. Agree. Submited Yes No 3 of 1 Pay. Sched. Submitted Yes No 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Section G - Subcontractors, Page 2 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location a Reference b c d e Projected Start Date f Projected End Date g Actual Start Date Request No. Sheet h Actual End Date 2 of i 1 SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 H - EDGE Name Tax ID Award Date Status Active Complete Void A B C D E F G H I J K L M N O P Q R S T Section H - EDGE, Page 1 of 0 SAO-F140-02v0408, ADM 5854 Contractor Payment Request Ohio Department of Administrative Services General Services Division State Architect's Office ▪ 4200 Surface Road ▪ Columbus, Ohio 43228-1395 Contractor Name Project Name Local No. Project Location a Reference b c d e Projected Start Date f Projected End Date g Actual Start Date Request No. Sheet h Actual End Date 3 of i 1 SAO Contract No. www.ohio.gov/sao e: StateArchOff@das.state.oh.us v: 614.466.4761 ▪ f: 614.644.7982 H - EDGE Name Tax ID Award Date Status Active Complete Void U V W X Y Z Section H - EDGE, Page 2 of 0 SAO-F140-02v0408, ADM 5854 Contractor Name Project Name SAO Contract No. Local No. Request No. I - Upload Project Location Data for Upload to Capital Improvement Projects Tracking System Project Project Number Local Project Number Project Name EDGE Waiver Agency Address City State Zip Code County Projected Start Date Projected End Date Actual Start Date Actual End Date Estimated Total Cost Project Status Original EDGE Goal Percent Revised EDGE Goal Percent Comments Contractor (Type C) Contract Number Local Contract Number Contract Type Contract Method EDGE Waiver Contract or Subcontract Award Date Projected Start Date Projected End Date Actual Start Date Actual End Date Estimated Total Cost Payments to Date Payment Request Number Date Contractor Signed Date Associate Signed SAO/Agency Approval Date As of Date Contract Status Original EDGE Goal Percent Revised EDGE Goal Percent Vendor FTID Vendor Name Vendor Address Vendor City Vendor State Vendor Zip Code Vendor County Vendor Phone Vendor Email Comments Sub/Supplier Data (Type S) Reference Projected Start Date Projected End Date Actual Start Date Actual End Date Estimated Total Cost Of Contract Type Name Tax ID Award Date Payments To Date A B C D E F G H I J K L M N O P Q R S T U V W X Y Z None None None None None None None None None None None None None None None None None Status None None None None None None None None None